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Consistent with the emphasis on systems’ approaches that have characterised much of the patient safety movement thus far, most existing efforts aimed at improving surgical safety tend to focus almost exclusively on perioperative care. For example, surgical quality committees spend the lion's share of their time discussing methods of ensuring optimal antibiotic prophylaxis to prevent wound infections or reining in the creative and highly variable ways surgeons use heparin (and its counterparts) to prevent deep venous thrombosis. Unfortunately, many of these initiatives have had only a modest impact on surgical outcomes.1

As a result, there has been growing enthusiasm for targeting the operation itself for improvement.2 Surgical procedures are complex, technical in nature and are particularly vulnerable to human error: outcomes may depend on the individual surgeon's ability to avert or mitigate technical errors. However, very little is known about the impact of surgical skill and technique on patient outcomes. Ironically, this may be attributable to the tendency of patient safety to focus on systems rather than individuals. Two other practical barriers to advancing the study of the contribution of individual technical skill and competence to surgical safety and quality include the following: (1) obtaining data on the details of what happens in the …

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